Development of professionalism : case study of HIV/AIDS-related stigma among healthcare students

A healthcare workforce that is responsive and fair in its treatment of patients is one of the central pillars of a modern health system (1). It is for this reason, among others, that healthcare workers are ethically bound to treat patients according to their need, and not according to their gender, religious beliefs, sexual orientation, skin color, or other socially (de)valued attribute. Within a modern healthcare program, there is also a focus on professional ethics and professional practice – often implicit rather than explicit probably increasing with the shift from pre-clinical to clinical years in a program. Hence, the years of training become a reasonable indicator of professionalization. A professional, however, is not simply brought into being. They are developed over time. When a student starts healthcare professional course, they would not be steeped in the ideas of the profession. By the time they have finished their university training, they may not be a fully-fledged professional, but they will, we would anticipate, be more professional. There is some anecdotal evidence, and preliminary empirical evidence to suggest that professionalization will affect attitudes in a healthcare setting, but will have a weaker effect on attitudes associated with the private, social sphere of a healthcare workers life (2). The conception and compilation of the code of professional conducts could be an explanation for the bifurcation of social attitudes. What one feels personally, should not affect the professional performance of that individual which subsequently should not affect the equality of the service provided. The Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) is a highly stigmatized condition(3–14). People with HIV have been divorced, thrown out of their homes and driven from their villages and lost their jobs (5); all because of that discrediting attribute. People with HIV have also been denied access to treatment and care by health professionals for the same reason (15),which has challenged the equitable delivery of services (3,16,17). There is some evidence to suggest, however, that there has been a bifurcation of social attitudes. One recent study suggested that health professionals may mentally ‘juggle’ two dissonant attitudes towards people living with HIV/AIDS (PLWHA), a professional attitude of fair treatment without regard to HIV status of the patient, and a social attitude of antipathy (18). In a lay, social sphere, HIV/AIDS remains a stigmatized condition(19–23). An interesting and important question arises from the bifurcation of social attitude. As healthcare professionals progress through their training, and acquire the norms of the profession including appropriate ethical practice and behavior, do their stigmatizing attitudes about HIV/AIDS reduce globally? Or, do their attitudes change within the limited sphere of the healthcare setting, leaving the attitudes they hold about the disease outside the healthcare untouched? Crudely, you might be prepared to treat the person, but would you want them as a friend? There is some anecdotal evidence, and preliminary empirical evidence to suggest that professionalization will affect attitudes in a healthcare setting, but will have a weaker effect on attitudes associated with the private, social sphere of a healthcare workers life (2). This question is important because it provides insight into the process of professionalization within healthcare professionals, and it provides insights into the process of managing disease related stigma in healthcare and non-healthcare settings. We hypothesized the following in our attempt to answer the question of what is the relationship between the professional development and changes in HIV/AIDS-related stigmatizing attitudes. The hypotheses were: 1. Healthcare students will demonstrate significant levels of disease related stigma. 2. The levels of disease related stigma among healthcare students will decrease significantly with increasing levels of professionalization. 3. On average, healthcare students will evaluate disease in healthcare situation in a less stigmatizing fashion than disease in social/private situation. 4. The rate of decreasing disease related stigma associated with increasing levels of professionalization will be greater for evaluations of disease in healthcare situations than for evaluations of disease in social/private situations. We created and validated a measurement tool to measure the levels of HIV/AIDS-related stigmatizing attitudes in two domains. That is a professional domain and a personal domain. Each domain represented the type of stigmatizing attitudes in each participant. We chose a novel non-parametric item response theory approach i.e., Mokken Scale Analysis (MSA) technique to develop and validate a brief unidimensional measure of personal domain of HIV/AIDS-related stigmatizing attitudes. We applied the Principal Component Analysis (PCA) technique to validate the measure of professional stigma scale. The initial items of the professional stigma scale were developed using modified Delphi technique. We administered the validated questionnaire to undergraduate medical and pharmacy students of Monash University in Australia and Malaysia in a two point-in-time fashion. The first round of data was collected during the first 2 months of the first semester of the Monash academic year i.e., March and April. The second round of data was collected during the ‘study vacation’ of the second semester i.e., October. The study vacation is the period in which students prepare for their exams – prior to the end of semester exams – when there are no teaching activities. There was, on average a 6-month time gap between the two data collections points. We also administered the validated questionnaire to undergraduate pharmacy students of Universiti Sains Malaysia (USM) in the month of October. At USM, academic calendar starts in the month of September. The ideal design for this research would be a 4-year to 5-year longitudinal study of healthcare students measuring changes in attitude over their professional course; however, an alternative approach was proposed to limit the resource expenditure while providing a good indication of the idea’s merit. Instead of a longitudinal design, a serial cross-sectional design (to examine differences between cohorts in different years of study) – please refer to Study I and Study II – was combined with a two-point in time longitudinal design (to examine differences between the beginning and the end of a single year of study) – please refer to Study III. Levels of stigma were measured once at the beginning of a single year of study and once at the end of the same year, and this was conducted across year cohorts. Study I was a cross-sectional survey of undergraduate pharmacy and medical students of Monash University in Australia and Malaysia. The fundamental finding of Study I was the ‘bifurcation’ of HIV/AIDS-related stigmatizing attitudes amongst healthcare students. As healthcare students became more professionalized their HIV/AIDS-related stigmatizing attitudes diverge across two domains: 1- The professional domain in which the behavioral intentions towards PLWHA are work related in a health working environment. 2- The personal domain in which the behavioral intentions towards PLWHA are at personal levels and in private situations. The HIV/AIDS-related stigmatizing attitudes, showed a significant –although small – decline for every year spent in the health programs i.e., pharmacy and medicine. The decline in the HIV/AIDS-related stigmatizing attitudes indicates the professionalization of HIV/AIDS stigmatizing attitudes amongst [future] healthcare professionals. Study II was a cross-sectional survey of undergraduate pharmacy students of Monash University Malaysia and USM. The two main findings were: 1) there were differences in HIV/AIDS-related stigmatizing attitudes between universities; 2) overall, the older cohorts did not show lower levels of HIV/AIDS-related stigmatizing attitudes. Although, Monash University pharmacy students showed a decline in the personal and professional HIV/AIDS-related stigmatizing attitudes, USM pharmacy students did not show significant decline in their stigmatizing attitudes. Moreover, there was no bifurcation of HIV/AIDS-related stigmatizing attitudes. We discussed the absence of bifurcation of stigmatizing attitudes and differences in professionalization of stigmatizing attitudes among Monash University and USM students by further exploring the differences in their curricula and teaching and learning activities. In Study III we collected the data in two points in time from undergraduate pharmacy and medical students of Monash University in Australia and Malaysia. There was an average a 6-month time period between the two data collection. The bifurcation of HIV/AIDS-related stigmatizing attitudes was present at the first point of data collection; however, the bifurcation was absent at the end of the 6-month period. We attempted to identify the reason(s) why the hypothesized relationship between professionalization and changes in stigmatizing attitudes did not hold.